Virginia Premier Health Plan Utilization Review RN in Glen Allen, Virginia

About Us

Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier. By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.

At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.

If this sounds like you, read on!

Overview

Responsible for authorizing cases according to approved criteria across the continuum of care to ensure a positive patient outcome while controlling costs by performing inpatient and outpatient reviews, and identification and referral of patients appropriate for case management.

Responsibilities

  • Obtains, review and enters clinical information from callers and on-site reviews according to VPHP’s policy and procedure manual for medical/behavioral health services requiring certification such as: pre-admission, admission, concurrent and retrospective review in VPHP’s computer systems.

  • Develops a complete understanding of and keeps current with customer requirements and uses knowledge as appropriate in utilization review process.

  • Reviews pre-certification requests within 1 business day of receipt to determine the medical necessity and appropriateness of care using established criteria. Refers questionable cases to the Medical Director .

  • Prepares and sends the appropriate certification or non-certification letter to the member, provider and hospital according to Virginia Premier Health Plan, Inc. (VPHP) policies and procedures.

  • Refers potential high-risk cases which will benefit from case management services to case management.

  • Interfaces with multidisciplinary staff to identify social factors impacting members’ illness and treatment.

  • Communicates effectively with customers while recognizing their various requirement and level of expertise with managed care.

  • Assesses social, economic, environmental and emotional factors that interfere with patient and family adjustment to illness and treatment and collaborate with case management to develop a plan of care.

  • Identifies and obtains needed community resources and provides feedback to external agencies on specified cases, as necessary.

  • Assist in the coordination of the psychosocial aspects of a member’s care plan.

  • Participates in VPHP’s ongoing quality improvement process.

  • Participates in continuing educational activities as appropriate.

  • This position provides services and demonstrates the knowledge and ability to meet the specific needs of all age groups.

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Current Virginia RN Licensure with demonstrated experience in Utilization Review; BSN preferred.

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees.

  • Demonstrates ability to negotiate with providers, vendors and other deliverers of services.

  • PC literate with working knowledge of Microsoft Word, Excel spreadsheet programs, and various computer software programs.

  • Working knowledge of resource options, and experience in making appropriate referrals.

  • Possess a working knowledge of ICD10 and CPT-4 coding.

  • Current Utilization Review experience.

WORK BACKGROUND/EXPERIENCE

  • Minimum of three years clinical experience and/or current managed care experience.

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

Our mission is to inspire healthy living within the communities we serve!

Job ID 2018-5390

As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.